Remnant of a non-patent ductus arteriosus mimicking traumatic thoracic aorta transection: a case report
© Apostolakis et al; licensee BioMed Central Ltd. 2010
Received: 8 November 2009
Accepted: 9 April 2010
Published: 9 April 2010
We present an interesting case of a 53-year-old man with a non-patent ductus arteriosus erroneously diagnosed as acute thoracic aorta transection after a car accident. The aortography revealed a "rupture" of the linear inner curve of the aorta in the isthmus area, as well as a protrusion of the aortic lumen in the corresponding area. During the followed thoracotomy an intact thoracic aorta and the remnant of a non-patent ligamentum arteriosum were found. It is the first reported case and we review all the possible entities which may give a false-positive image of traumatic aortic transection.
Aortography was for many years the "gold standard" in diagnosis of acute traumatic aortic rupture against the two other methods of diagnostic imaging: CT-angiography and transesophageal ECHO . Its sensitivity and specificity in experienced hands approaches 100% . However, in rare cases a false-positive or false-negative imaging may be observed. For the false positive images of traumatic rupture the most common causes are local atherosclerotic lesions of the aortic wall, ductal diverticula , remnant of non-patent ductus arteriosus or pre-existent aneurysm of the isthmus area . We describe herein a case of an injured patient with high-suspicion index of traumatic aortic rupture, which was based on a false-positive aortography.
In every case of suspicion of traumatic aortic transection, the imaging diagnosis is based on spiral CT-angiography or transesophageal echocardiography (TEE), and rarely on the conventional aortography. Aortography is considered as the exam with the higher specificity and sensibility approaching the 100% . However, rare preexistent pathological conditions may obscure the clearness of these imaging examinations. Indeed, these conditions may mimic an aortic rupture and in this way give false-positive results. Therefore, it should be taken under consideration by the operator of the angio-CT, or of the TEE, to avoid any pitfall for the final diagnosis. The four rare entities which may give false-positive imaging of aortic rupture in the region of the isthmus are the following. A. Remnant of a non-patent ductus arteriosus. This vestigial may appear as a local protrusion of the aortic extremity of the ductus-as in our case- or as a scarry remnant which on the CT angiography creates a transformation and an angulation with compression between aorta and pulmonary artery (scarry remnant forming the "corner point" of a compression between aorta and pulmonary artery) . On this remnant of the ductus arteriosus may be developed later in the adult life, infective endocarditis .
B. Aneurysm of a non-patent ductus arteriosus. They usually arise from the aortic extreme of the ductus and may compress the nearest organs like trachea and esophagus, giving related symptoms [4, 5]. C. Aortic diverticulum. It is commonly thought to be a remnant of the closed ligamentum or ductus arteriosus. However some authors support the hypothesis that it is a remnant of the right dorsal aortic root . It is described in thoracic aortography as a large bulge on the lesser curvature of the aortic isthmus, in patients with a left aortic arch and normal origin of the brachiocephalic arteries.
D. Calcification of the ligamentum arteriosum and/or of the aortic wall in the aortic isthmus area. This calcification in the adults may be in several patterns such as curvilinear, punctate or clumped, and in incidence up to 65% . In our case, we chose the surgical instead of the endovascular-intervention, for the following two reasons. First, because an endovascular graft was not in time available, and second, there were no contraindications for surgical intervention (brain injury, coagulation's abnormalities, etc). Despite of absence of signs of aortic transection during the inspection of the thoracic aorta (intramural hematoma, periaortic infiltration, etc), the image of aortography posed us in a dilemma, taken in consideration our experience and the bibliographic data; there is not traumatic aortic rupture without haematic infiltration. According these data, we decided open the aorta to elucidate the differential diagnosis about the given image of aortography.
Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
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